際際滷

際際滷Share a Scribd company logo

HX2 history taking skills for medical st.ppt

Download as PPT, PDF
M
M H

The document provides guidance on conducting a thorough patient history. It emphasizes the importance of listening to the patient, as the symptoms they describe may indicate the diagnosis. The history includes sections on the chief complaint, history of present illness, review of symptoms affecting various body systems, past medical and surgical history, family history, social history, immunization history, and gynecological/obstetric history for women. Taking a complete history is a fundamental clinical skill that provides crucial information to identify the patient's concerns and medical conditions.

1 of 17
Download to read offline
HISTORY TAKING Always listen to the patient they might be telling you the Diagnosis Sir William Osler (1849-1919) PREPARED BY: DR.RUQAYA AL-KATHIRY HEAD OF THE MEDICAL DEPARTMENT IN UST
*The clinical consultation comprises 3 components: 1-History taking 2-Physical examination 3-Diagnosis *The pt. seeks medical help for 3 reasons: 1-Diagnostic Purposes (Dx) 2-Treatment (Rx) 3-Reassurance?? Thus the Dr. should build up a strong patient-doctor relationship which is established in the 1st meeting during Hx talking. The Dr. should put the pt. at ease & encourage him/her to talk freely. The art of history taking is the most fundamental skill in medicine. It can be acquired by: 1-Good teaching before and after qualifying 2-Careful observation of others how they take histories 3-A willingness to invite or accept comments & criticism 4-Constant self-scrutiny
HISTORY TAKING 1-PERSONAL HISTORY (Hx): -Name -Age -Gender -Marital status -Address -Occupation -Religion -Date & time of admission through: ER / OPD / Referral paper Q. IS IT IMPORTANT TO KNOW? N.B: Special habits may be included here e.g. smoking, alcohol, qat chewing, drugs abuse. 2-CHIEF COMPLAINT (C/C): The problem which made the pt. seek medical advice. *It should be recorded in the pt.s own words rather than medical terms. *The time & duration of symp. in chronological order (the 1st to the last). *As short as possible i.e. only 1 complaint (the most important) maximum 3.
3-HISTORY OF PRESENT ILLNESS (HOPI): *Ask the pt. to tell you the story of the illness from the beginning up to date. *Do not interrupt (BE A GOOD LISTENER) unless the pt. is talkative & is not near the point (TAKE CONTROL) or to encourage a nervous one. *Gently discourage a pt. who uses medical terms without really knowing their meaning & ask them to describe what they actually feel. *Begin talking to the pt.; clarification may be sought from relatives/friends. *Understand the pt.'s story clearly then analyze each main symptom in turn. *Avoid, as far as possible leading questions which suggest an answer, although direct questions may be essential. *Consider the course of the illness: Q. Did it begin insidiously and gradually worsen or intermittent (relapses or remissions)? Q. Is it of acute onset slowly getting better, but not yet gone? *Use medical terms with chronological development of the condition with precise dates. *Mention the +ve & important -ve symptoms as they may indicate the specific involvement of a system.
4-REVIEW OF OTHER SYSTEMS (ROS): This is a guide to not miss anything. -Symptoms of the related system should be described in the HOPI not in ROS. Q.ASSIGNMENT: DEFINE ALL THESES SYMPTOMS. CARDIOVASCULAR SYSTEM: -CHEST PAIN: (SOCRATE) -DYSPNEA -ORTHOPNEA -PAROXYSMAL NOCTURNAL DYSPNEA -COUGH -SPUTUM -HAEMOPTYSIS -PALPITATION -OEDEMA -SYNCOPE -CLAUDICATION -CHANGE IN THE COLOUR OF THE FEET RESPIRATORY SYSTEM: -COUGH -SPUTUM -HAEMOPTYSIS -DYSPNEA -CHEST PAIN: (SOCRATE) -WHEEZE -STRIDOR -SYSTEMIC MANIFESTATIONS:-FEVER-SWEATING-RIGORS-CHILLS
GASTROINTESTINAL SYSTEM: -CHANGE OF APETITE: ANOREXIA / POLYPHAGIA -WEIGHT CHANGES -HALITOSIS -SALIVATION CHANGES: XEROSTOMIA / PTYALISM -BELCHING -WATER BRUSH -HEARTBURN -DYSPHAGIA -ODYNOPHAGIA -HICCUPS -DYSPEPSIA -NAUSEA -VOMITING -ABDOMINAL PAIN: (SOCRATE) -FLATULENCE -BLOATING -CHANGE IN BOWEL HABIT: CONSTIPATION / DIARRHOEA -HAEMATEMESIS -MELAENA -HAEMATOCHEZIA -JAUNDICE
GENITOURINARY SYSTEM: *URINARY SYMPTOMS: -DYSURIA -FREQUENCY -INCONTINENCE -URGENCY -HESITANCY -NOCTURIA -HAEMATURIA -CHANG IN THE AMOUNT OF URINE: POLYURIA OLIGURIA ANURIA -LOIN PAIN: (SOCRATE) *GENITAL SYMPTOMS: -URETHRAL DISCHARGE -ITCHING -PAIN / DISCOMFORT -SEXUAL HISTORY: if suspected STD -IMPOTENCE -INFERTILITY
NEUROLOGICAL SYSTEM: -HEADACHE: (SOCRATE) -FITS / SEIZURES / CONVULSIONS -FAINT / SYNCOPE -CONCIOUSNESS DISTURBANCE -PERSONALITY CHANGES -DISTURBANCE OF VISION SMELL TASTE HEARING SPEECH SLEEP -PHOTOPHOBIA -EYE PAIN -DIPLOPIA -FACIAL PAIN OR NUMBNESS -VERTIGO -LOSS OF SPHINCTER CONTROL -MUSCLE WEAKNESS/PARALYSIS -ABNORMAL MOVEMENTS SENSATION
ENDOCRINE SYSTEM: -HEAT / COLD INTOLERANCE -HYPERHYDROSIS / ANHYDROSIS -PALPITATION, TREMORS & PERSPIRATION -SKIN PIGMENTATION & WEIGHT CHANGES -POLYURIA,POLYDIPSIA & POLYPHAGIA -CHANGE IN THE SIZE OF HAND & FEET -IMPOTENCE -IMPAIRED FERTILITY -HIRSUTISM / HAIR LOSS -MYOPATHY HAEMATOLOGICAL SYSTEM: -LASSITUDE, DYSPNEA & PALPITATION -INFECTION -BLOOD LOSS, EASY BRUISING -SWELLING & GLANDULAR ENLARGEMENT: LYMPH NODES SPLEEN BONE MENINGES ORBITS
GENERAL: -WEIGHT CHANGE -APETITE CHANGE -WEAKNESS -FATIGUE -FEVER -LUMPS -EAR DISCHARGE -MOUTH & THROAT PAIN -NECK PAIN OR LUMP DERMATOLOGICAL SYSTEM: -SKIN RASH -DISTRIBUTION -ITCHING LOCOMOTOR SYSTEM: -PAIN: BONE, JOINT, MUSCLE (SOCRATE) -SWELLING -WEAKNESS -DEFORMITY
5-PAST HISTORY: *MEDICAL HISTORY: Chronic diseases: as D.M, heart disease, HT, COPD, T.B, B.A, PUD, liver cirrhosis, epilepsy, hypothyroidism. Previous hospitalizations: for a similar condition or others. *SURGICAL HISTORY Surgical operations: nature (i.e. major/minor), date & complications. History of trauma: type of accidents & date. Blood transfusions: amount (i.e. 250ml/500ml=1/2 or 1 pint of blood), date & indications. 6-FAMILY HISTORY: *MEMBERS: PARENTS & WIFE/HUSBAND: Consanguinity SIBLINGS & CHILDREN: : No. Alive= Age & health status Dead= Age & cause *SIMILAR CONDITION IN THE FAMILY. *HISTORY OF ANY IN WHICH HEREDITARY OR ENVIRONMENTAL FACTORS MAY PLAY A ROLE:
D.M HT IHD B.A T.B Thyroid disease Blood Diseases CA (Breast, colon, prostate) Schizophrenia
7-DRUG HISTORY: *PRESCRIBED DRUGS: Identity (name) of the drug Route of administration (po=per orum=by mouth) Dose (mcg, mg, g) Frequency of administration o o.d =once daily o b.d (bis die)=twice daily o t.d.s (ter die sumendus) / t.i.d (ter in die)=thrice daily o q.d.s (quarter die sumendus) / q.i.d (quarter in die)=four times/d Compliance *NON-PRESCRIBED DRUGS: Over the counter (OTC): analgesics; OCPs; psychotropic drugs; vitamins Herbal remedies Laxatives *DRUG ALLERGIES: FAILURE TO ASK THE QUESTION OR TO RECORD THE ANSWER PROPERLY MAY BE LETHAL. -What type of reaction? -Other allergies? as food, seasonal or latex *DRUG INTERACTIONS:
8-SOCIOECONOMIC HISTORY: Diet: regular; type (e.g. vegetarian) Exercise: regular; lift / stairs Smoking: smoking index :no. of cigarettes / days X years Q.WHAT IS ITS SIGNIFICANCE?WHAT ARE THE TOBACCO RELATED DISEASES? Alcohol: duration; type & amount; Q.WHAT ARE THE ALCOHOL RELATED DISEASES? Qat chewing: duration & amount Occupation: type; hours; potential hazards (e.g. chemicals) Housing: owned / rented; rural / urban; occupants; rooms; bathrooms; electricity; ventilation; water supply; heating & sewage system. Animal Contact: animal breeding: type & duration Financial Status: low; moderate; good income Traveling Abroad: when & where Recent stresses or worries 9-IMMUNISATION HISTORY: -If small child or elderly patient. -Should be taken from the care giver
10-GYNAECOLOGICAL AND OBSTETRIC HISTORY: *MENSTRUAL HISTORY: L.M.P Menarche Postmenopause Days / Month Amount of blood loss Dysmenorrhea Premenstrual Tension *OBSTETRIC HISTORY: No. of pregnancies (Full-term / Preterm) Complications of pregnancies Miscarriages (Abortions) (G=P+A)
Medicine is learned at the bedside and not in the classroom Sir William Osler (1849-1919)
THANK YOU FOR YOUR ATTENDANCE

More Related Content

HX2 history taking skills for medical st.ppt

  • 1. HISTORY TAKING Always listen to the patient they might be telling you the Diagnosis Sir William Osler (1849-1919) PREPARED BY: DR.RUQAYA AL-KATHIRY HEAD OF THE MEDICAL DEPARTMENT IN UST
  • 2. *The clinical consultation comprises 3 components: 1-History taking 2-Physical examination 3-Diagnosis *The pt. seeks medical help for 3 reasons: 1-Diagnostic Purposes (Dx) 2-Treatment (Rx) 3-Reassurance?? Thus the Dr. should build up a strong patient-doctor relationship which is established in the 1st meeting during Hx talking. The Dr. should put the pt. at ease & encourage him/her to talk freely. The art of history taking is the most fundamental skill in medicine. It can be acquired by: 1-Good teaching before and after qualifying 2-Careful observation of others how they take histories 3-A willingness to invite or accept comments & criticism 4-Constant self-scrutiny
  • 3. HISTORY TAKING 1-PERSONAL HISTORY (Hx): -Name -Age -Gender -Marital status -Address -Occupation -Religion -Date & time of admission through: ER / OPD / Referral paper Q. IS IT IMPORTANT TO KNOW? N.B: Special habits may be included here e.g. smoking, alcohol, qat chewing, drugs abuse. 2-CHIEF COMPLAINT (C/C): The problem which made the pt. seek medical advice. *It should be recorded in the pt.s own words rather than medical terms. *The time & duration of symp. in chronological order (the 1st to the last). *As short as possible i.e. only 1 complaint (the most important) maximum 3.
  • 4. 3-HISTORY OF PRESENT ILLNESS (HOPI): *Ask the pt. to tell you the story of the illness from the beginning up to date. *Do not interrupt (BE A GOOD LISTENER) unless the pt. is talkative & is not near the point (TAKE CONTROL) or to encourage a nervous one. *Gently discourage a pt. who uses medical terms without really knowing their meaning & ask them to describe what they actually feel. *Begin talking to the pt.; clarification may be sought from relatives/friends. *Understand the pt.'s story clearly then analyze each main symptom in turn. *Avoid, as far as possible leading questions which suggest an answer, although direct questions may be essential. *Consider the course of the illness: Q. Did it begin insidiously and gradually worsen or intermittent (relapses or remissions)? Q. Is it of acute onset slowly getting better, but not yet gone? *Use medical terms with chronological development of the condition with precise dates. *Mention the +ve & important -ve symptoms as they may indicate the specific involvement of a system.
  • 5. 4-REVIEW OF OTHER SYSTEMS (ROS): This is a guide to not miss anything. -Symptoms of the related system should be described in the HOPI not in ROS. Q.ASSIGNMENT: DEFINE ALL THESES SYMPTOMS. CARDIOVASCULAR SYSTEM: -CHEST PAIN: (SOCRATE) -DYSPNEA -ORTHOPNEA -PAROXYSMAL NOCTURNAL DYSPNEA -COUGH -SPUTUM -HAEMOPTYSIS -PALPITATION -OEDEMA -SYNCOPE -CLAUDICATION -CHANGE IN THE COLOUR OF THE FEET RESPIRATORY SYSTEM: -COUGH -SPUTUM -HAEMOPTYSIS -DYSPNEA -CHEST PAIN: (SOCRATE) -WHEEZE -STRIDOR -SYSTEMIC MANIFESTATIONS:-FEVER-SWEATING-RIGORS-CHILLS
  • 6. GASTROINTESTINAL SYSTEM: -CHANGE OF APETITE: ANOREXIA / POLYPHAGIA -WEIGHT CHANGES -HALITOSIS -SALIVATION CHANGES: XEROSTOMIA / PTYALISM -BELCHING -WATER BRUSH -HEARTBURN -DYSPHAGIA -ODYNOPHAGIA -HICCUPS -DYSPEPSIA -NAUSEA -VOMITING -ABDOMINAL PAIN: (SOCRATE) -FLATULENCE -BLOATING -CHANGE IN BOWEL HABIT: CONSTIPATION / DIARRHOEA -HAEMATEMESIS -MELAENA -HAEMATOCHEZIA -JAUNDICE
  • 7. GENITOURINARY SYSTEM: *URINARY SYMPTOMS: -DYSURIA -FREQUENCY -INCONTINENCE -URGENCY -HESITANCY -NOCTURIA -HAEMATURIA -CHANG IN THE AMOUNT OF URINE: POLYURIA OLIGURIA ANURIA -LOIN PAIN: (SOCRATE) *GENITAL SYMPTOMS: -URETHRAL DISCHARGE -ITCHING -PAIN / DISCOMFORT -SEXUAL HISTORY: if suspected STD -IMPOTENCE -INFERTILITY
  • 8. NEUROLOGICAL SYSTEM: -HEADACHE: (SOCRATE) -FITS / SEIZURES / CONVULSIONS -FAINT / SYNCOPE -CONCIOUSNESS DISTURBANCE -PERSONALITY CHANGES -DISTURBANCE OF VISION SMELL TASTE HEARING SPEECH SLEEP -PHOTOPHOBIA -EYE PAIN -DIPLOPIA -FACIAL PAIN OR NUMBNESS -VERTIGO -LOSS OF SPHINCTER CONTROL -MUSCLE WEAKNESS/PARALYSIS -ABNORMAL MOVEMENTS SENSATION
  • 9. ENDOCRINE SYSTEM: -HEAT / COLD INTOLERANCE -HYPERHYDROSIS / ANHYDROSIS -PALPITATION, TREMORS & PERSPIRATION -SKIN PIGMENTATION & WEIGHT CHANGES -POLYURIA,POLYDIPSIA & POLYPHAGIA -CHANGE IN THE SIZE OF HAND & FEET -IMPOTENCE -IMPAIRED FERTILITY -HIRSUTISM / HAIR LOSS -MYOPATHY HAEMATOLOGICAL SYSTEM: -LASSITUDE, DYSPNEA & PALPITATION -INFECTION -BLOOD LOSS, EASY BRUISING -SWELLING & GLANDULAR ENLARGEMENT: LYMPH NODES SPLEEN BONE MENINGES ORBITS
  • 10. GENERAL: -WEIGHT CHANGE -APETITE CHANGE -WEAKNESS -FATIGUE -FEVER -LUMPS -EAR DISCHARGE -MOUTH & THROAT PAIN -NECK PAIN OR LUMP DERMATOLOGICAL SYSTEM: -SKIN RASH -DISTRIBUTION -ITCHING LOCOMOTOR SYSTEM: -PAIN: BONE, JOINT, MUSCLE (SOCRATE) -SWELLING -WEAKNESS -DEFORMITY
  • 11. 5-PAST HISTORY: *MEDICAL HISTORY: Chronic diseases: as D.M, heart disease, HT, COPD, T.B, B.A, PUD, liver cirrhosis, epilepsy, hypothyroidism. Previous hospitalizations: for a similar condition or others. *SURGICAL HISTORY Surgical operations: nature (i.e. major/minor), date & complications. History of trauma: type of accidents & date. Blood transfusions: amount (i.e. 250ml/500ml=1/2 or 1 pint of blood), date & indications. 6-FAMILY HISTORY: *MEMBERS: PARENTS & WIFE/HUSBAND: Consanguinity SIBLINGS & CHILDREN: : No. Alive= Age & health status Dead= Age & cause *SIMILAR CONDITION IN THE FAMILY. *HISTORY OF ANY IN WHICH HEREDITARY OR ENVIRONMENTAL FACTORS MAY PLAY A ROLE:
  • 12. D.M HT IHD B.A T.B Thyroid disease Blood Diseases CA (Breast, colon, prostate) Schizophrenia
  • 13. 7-DRUG HISTORY: *PRESCRIBED DRUGS: Identity (name) of the drug Route of administration (po=per orum=by mouth) Dose (mcg, mg, g) Frequency of administration o o.d =once daily o b.d (bis die)=twice daily o t.d.s (ter die sumendus) / t.i.d (ter in die)=thrice daily o q.d.s (quarter die sumendus) / q.i.d (quarter in die)=four times/d Compliance *NON-PRESCRIBED DRUGS: Over the counter (OTC): analgesics; OCPs; psychotropic drugs; vitamins Herbal remedies Laxatives *DRUG ALLERGIES: FAILURE TO ASK THE QUESTION OR TO RECORD THE ANSWER PROPERLY MAY BE LETHAL. -What type of reaction? -Other allergies? as food, seasonal or latex *DRUG INTERACTIONS:
  • 14. 8-SOCIOECONOMIC HISTORY: Diet: regular; type (e.g. vegetarian) Exercise: regular; lift / stairs Smoking: smoking index :no. of cigarettes / days X years Q.WHAT IS ITS SIGNIFICANCE?WHAT ARE THE TOBACCO RELATED DISEASES? Alcohol: duration; type & amount; Q.WHAT ARE THE ALCOHOL RELATED DISEASES? Qat chewing: duration & amount Occupation: type; hours; potential hazards (e.g. chemicals) Housing: owned / rented; rural / urban; occupants; rooms; bathrooms; electricity; ventilation; water supply; heating & sewage system. Animal Contact: animal breeding: type & duration Financial Status: low; moderate; good income Traveling Abroad: when & where Recent stresses or worries 9-IMMUNISATION HISTORY: -If small child or elderly patient. -Should be taken from the care giver
  • 15. 10-GYNAECOLOGICAL AND OBSTETRIC HISTORY: *MENSTRUAL HISTORY: L.M.P Menarche Postmenopause Days / Month Amount of blood loss Dysmenorrhea Premenstrual Tension *OBSTETRIC HISTORY: No. of pregnancies (Full-term / Preterm) Complications of pregnancies Miscarriages (Abortions) (G=P+A)
  • 16. Medicine is learned at the bedside and not in the classroom Sir William Osler (1849-1919)
  • 17. THANK YOU FOR YOUR ATTENDANCE